AHP’s Care Management: Using the Arcadia Dashboard to help manage patients
June 29th, 2016 | ArchiveAfter featuring the committed and talented people who serve as AHP care managers, Network News will now include periodic care management success stories. AHP’s care management program was developed to support physician efforts to deliver care to some of their most complex patients, and this recurring feature will highlight some of those stories.
Tiffany King, BSN, RN is an AHP care manager embedded with a community physician group. She shares this experience:
AHP care managers use The Arcadia Analytics Software to identify high risk patients and drive outreach that helps ensure high quality care. A particular case that stands out in my mind is one where I was working with an Arcadia-identified high risk patient who had several repeat admissions to the hospital for a behavioral health disorder. The patient’s family was adamant about keeping her in their home and providing care. Social workers and inpatient providers advocated for the patient to go to a nursing home and after the third admission in a month, the family agreed to try it. The patient was transferred to a nursing home close to the family’s residence where she remained for a little over a month. While she was there, her condition improved and the patient’s functioning significantly improved. She then wanted to return home and her family agreed with this plan.
After her discharge, I decided to make a home visit to ensure that the patient and family understood the patient’s new medication regimen and the importance of continuing them as prescribed in order to effectively manage her condition. I organized a family meeting and educated them in detail about each medication, what it does, when to give it, and the importance of taking them exactly as prescribed. We concluded that not only was there confusion around the medications but there were too many people involved in managing the patient’s medications, causing errors such as multiple missed doses. I suggested assigning one person to oversee the patient’s medications as well as using a weekly pill box to help organize medications by day and time. We also identified that an essential medication was missing from the patient’s regimen. I was able to secure an order from the patient’s physician, obtain the medication and add it to the pill box.
I believe that this is a great example of how Arcadia can be leveraged to identify high-risk patients. For this patient it resulted in care management advocacy and intervention that prevented a poor outcome and possibly an unnecessary hospital readmission. The one-on-one, in-home education with the patient and family was very beneficial in this case. We worked together to create an organized plan of care for the patient allowing her to remain safe and at home.
